APPLICATION FOR BOILER AND PRESSURE VESSEL

INSPECTORS’ EXAMINATION

I hereby make application for a Boiler and Pressure Vessel Inspectors’ Examination, and certify that the
following statements are correct:

Name in full: Age: Date of Birth:

(Print or type) mo./day/yr.

Present residence:
(Street Address, City/Province, State, Country, Zip Code)

Name and address of employer:

(Street Address, City/Province, State, Country, Zip Code)

1. School Education Degree

(M.E., E.E, C.E., etc)
2. BOILER SHOP EXPERIENCE
Employer’s Name *Period of Employment Employed as
From to
From to
From to
3. BOILER INSTALLATION EXPERIENCE
Employer’s Name *Period of Employment Employed as
From to
From to
From to
4. BOILER OPERATING EXPERIENCE
Employer’s Name *Period of Employment Employed as
From to
From to
From to
5 BOILER INSPECTION EXPERIENCE
Employer’s Name *Period of Employment Employed as
From to
From to
From to
* Give month and year of each period of employment.
6. Jurisdictional and National Board written examination taken in Dates
(State of United States or Province of Canada)

An exam fee of $50 should accompany this application. Checks or money orders are to be made payable to the
TREASURER OF VIRGINIA.

Mail to: Virginia Department of Labor and Industry

Boiler Safety Compliance Program
Powers-Taylor Building
13 South Thirteenth Street
Richmond, Virginia 23219 Signature of Applicant

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